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A patient with Marfan's syndrome was seen at 29 weeks' gestation with acute aortic dissection. She underwent aortic root replacement under deep hypothermia and circulatory arrest. The fetal heart rate was ominous during surgery but recovered later. Serial ultrasonographic examinations showed progressive fetal brain atrophy. The patient was delivered at 38 weeks' gestation of a girl weighing 2305 g, in whom severe spastic tetraplegia, absent psychomotor development, and therapy-resistant epilepsy developed. This is the first case to document progressive fetal brain atrophy after cardiac surgery in pregnancy.

Objective: To study the characteristics of birthweight and gestational age of third trimester fetal deaths which occurred before the onset of labour., Design: Review of computerised confidential perinatal mortality records. Data originated from the 1992 Trent Region Perinatal Mortality Survey., Sample: One hundred and forty-nine antepartum stillbirths of at least 24 weeks of gestation confirmed by early ultrasound scan. Congenital abnormalities and multiple pregnancies were excluded., Main Outcome Measures: Reported causes of stillbirth; weight-for-gestational age centiles based on a standard derived from normal pregnancies; pregnancy characteristics compared with the local maternity population., Results: Of 149 stillbirths, 83 (56%) were preterm and 66 were at term, and the majority (126; 85%) occurred from 31 weeks. Most of the deaths (97; 65%) were reported as 'unexplained' even though post-mortems had been carried out in 60% of all cases. Using a gestational age-specific fetal weight standard derived from normal, term live births, 41% of all cases of stillborn infants were small-for-gestational age (< 10th centile; OR 6.2; 95% CI 3.3-11.5); 39% of which had been classified as unexplained were small for gestational age (OR 5.6; 2.6-12.0). This excess of small stillbirths was most pronounced between 31 and 33 weeks, where the weights of 63% of all stillbirths and 72% of unexplained fetal deaths were < 10th centile. Overall, a higher proportion of preterm (< 37 weeks) than term stillbirths were small for gestational age: 53% vs 26% (OR 3.3; 1.6-6.5). However, at term there were also more subtle differences in weight deficit, with more fetuses with a weight between the 10th and 50th centiles than between 50th and 90th (36 vs 11; OR 3.3; 1.4-7.8). Mothers of pregnancies ending in stillbirth were similar in age, size, parity and ethnic group to mothers of live born babies, but were more likely to be smokers (37 vs 27%, OR 1.6; 1.2-2.3)., Conclusions: Many stillborn babies are small for gestational age. In the absence of significant differences in physiological pregnancy characteristics, this is unlikely to be a constitutional smallness, but represents a preponderance of intrauterine growth restriction. For a full appreciation of the strength of this association, appropriate weight standards and classifications need to be applied in perinatal mortality surveys. Many antepartum stillbirths which are currently designated as unexplained may be avoidable if slow fetal growth could be recognised as a warning sign.

The objective of this study was to investigate the size of singleton vs twin pregnancies at the time of a second trimester dating scan. The analysis included 86 infants from 63 pregnancies achieved with assisted reproductive techniques, comprising 40 singletons and 46 twins. Measurements of second trimester biparietal diameter (n = 85) and femur length (n = 74) were plotted against the precisely known gestational age. A common regression line was calculated for each parameter and the residuals for singletons and twins were compared. Gestational age and weight at birth were also analysed for each group. There was no significant difference between singletons and twins in biparietal diameter or femur length in second trimester. In contrast, twins had a lower mean birthweight, gestational age at birth, and weight-for-gestational age centile compared with singletons. Singleton babies from these pregnancies had an average birthweight centile of 49.8% (i.e. close to the median for spontaneously conceived pregnancies in our population). We concluded that the same pregnancy dating charts can be used for singletons and twins. At corresponding gestational age, twins are smaller than singletons at birth because of slower growth in the third trimester.

IUGR puts the fetus at risk of stillbirth, perinatal morbidity and neonatal handicap, yet most instances of IUGR are not recognized. Progress has been made in recent years to monitor the high-risk fetus with intensive biometric and biophysical tests and to determine the appropriate time for intervention. These methods of surveillance are ineffective and inappropriate for population screening, and the main problem remains how to identify the at-risk fetus. Improvement of current performance requires the establishment of appropriate standards by which intrauterine growth can be assessed, and their introduction as part of well-organized screening programmes. We describe a computerized method of predicting the optimal weight for each pregnancy, which is individually adjusted for non-pathological variables such as maternal height, booking weight, ethnic group and parity. The optimal birthweight determines the expected slope or velocity of fetal weight gain. This individualized prediction improves the distinction between constitutional and pathological smallness. Furthermore, preterm weights are measured against a fetal weight norm rather than a birthweight standard that is derived from non-physiological preterm deliveries. The customized growth chart allows screening for growth retardation by determining the growth velocity through serial measurement and plotting of fundal height, backed up as necessary by ultrasound estimation of fetal weight and referral for more intensive surveillance as indicated.

Incompetent communicating or perforating veins are often responsible for recurrent varicose veins with skin changes at the lower leg, especially in the postthrombotic syndrome. Subcutaneous and subfascial surgical explorations carry a 35% complication rate. We used a new endoscopic technique to locate and ligate communicating veins with the objective to decrease this complication rate. Through a short skin incision on the anteromedial side of the proximal 1/3 of the lower leg the fascia is incised over 2 cm and the subfascial space opened by finger dissection. A mediastinoscope (length 18 cm; diameter 12 mm) is inserted and pushed down beneath the fascia to the level of the malleolus. Under direct vision the communicating veins crossing this space are located and ligated with haemoclips. In 48 patients, 15 male and 33 female, with a mean age of 53 (22-73) years, 54 legs were treated: 40 legs showed recurrent varicose veins, due to incompetent communicating veins with severe skin changes and ulcers, and 14 had primary varicosis. All patients complained of fatigue and pain. In 49 legs (44 patients) relief of preoperative complaints was obtained and in 5 (4 patients) there was no change. Two indurated wounds and 1 dehiscent wound were treated conservatively. One patient, operated on both legs, developed a severe subfascial infection on both sides necessitating a reintervention. The advantages of the subfascial endoscopic technique, a fast operative procedure, fewer postoperative wound infections (9.3%), a good cosmetic effect, and a low (2.5% after 3.8 years) recurrent ulcer rate make it a valuable new method for treating incompetent communicating veins.